Provider Demographics
NPI:1962130443
Name:PEDIATRICS PRIMARY CARE CLINIC LLC
Entity type:Organization
Organization Name:PEDIATRICS PRIMARY CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:318-794-2428
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:LA
Mailing Address - Zip Code:71430-0457
Mailing Address - Country:US
Mailing Address - Phone:318-794-2428
Mailing Address - Fax:
Practice Address - Street 1:11098 HIGHWAY 165 S
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:LA
Practice Address - Zip Code:71430-9789
Practice Address - Country:US
Practice Address - Phone:318-368-1236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health